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Case Study

Healthfirst rapidly onboards membership amidst COVID-19 disruption

  • Accelerated business transformation during the COVID-19 pandemic
  • Modernized member enrollment, claims, and provider lifecycle management
  • Delivered more efficient, digital service across the board

“Before Pega, we were trapped in legacy monoliths that had rules embedded in decades of code. Change used to be hard for us, but now with Pega, we're able to adapt to change more quickly and have been able to keep up with the unprecedented need for agility during COVID-19.”

The Business Issue

Healthfirst, the largest nonprofit health insurer in New York, was in the process of modernizing its core operations – using Pega at the center of its digital architecture – when the COVID-19 pandemic hit.

As the pandemic unfolded, Healthfirst experienced a 15% surge in membership – with the enrollment of over 250,000 New Yorkers. Healthfirst’s legacy enrollment process was built for first-time enrollment but not for maintenance. 

With shutdown-induced eligibility changes during the public health crisis; upheaval for Healthfirst’s members, providers, sponsor hospitals, and staff; and real-time regulatory changes, the organization knew that streamlined enrollment was critical to success.

The Solution

Prior to the pandemic, Healthfirst used the Pega Platform™ across the organization to modernize its core administration functions – namely, enrollment, claims, authorizations, payments, and provider lifecycle management. 

Healthfirst’s modern enrollment platform uses Pega’s HIPAA 834 model and intelligent automation to identify the transaction type, route the work to the right process, and automate the process as much as possible. Compliance rules are now easily accessible and can be quickly updated, allowing Healthfirst to instantly adapt to any market condition.

The Results

With Pega, Healthfirst felt prepared throughout the pandemic and grew increasingly confident. Healthfirst’s stakeholders are receiving enormous benefits from this digital transformation journey. Here’s what the organization has achieved so far: 

  • Seamlessly enrolled over 250,000 new members during the pandemic
  • Processed 98% of enrollment transactions automatically
  • Maintained flat enrollment costs despite record transactional volume
  • Reduced provider onboarding process time by 77% 
  • Fully automated 75% of provider data management updates 
  • Increased claims processing first pass rate to 92%
  • Auto-processed 40% of prior authorizations
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Industry: Healthcare Product Area: Platform Solution Area: Enterprise Modernization Solution Area: Operational Excellence
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